Dyspnea And Chest Pain In An Adolescent - Soccer

Abstract

HISTORY A 16-year old high school soccer player was running at the conclusion of practice and developed sudden onset dyspnea with retrosternal pain. His shortness of breath and chest pain continued unchanged through the night and he presented to his pediatrician the following morning. There is no history of trauma, fever, cough or asthma. Our patient reported increasing fatigue, abdominal pain, muscle aches, and malaise for two to three days prior to the presenting event. He participated in wrestling during the previous sports season. PHYSICAL EXAMINATION VS: HR 80 bpm, RR 45 breaths/min, BP 135/79 mmHg, Temp 36.6°C, SaO2 97% on room air. General: mild to moderate distress, breathing through pursed lips intermittently, ambulatory and talkative. Cardiovascular: heart - regular rate and rhythm, without murmur, normal pulses, capillary refill is less than two seconds. Pulmonary: lungs clear to auscultation, no increased resonance with percussion, no retractions, crackles or wheezes. Abdomen: mild subcostal tenderness bilaterally, no hepatosplenomegaly, masses or costovertebral angle tenderness, good bowel sounds, soft and nondistended. Extremities: no calf tenderness, Homan's sign was negative. DIFFERENTIAL DIAGNOSIS Spontaneous Pneumothorax Pulmonary Embolism Pericardial tamponade Asthma TEST AND RESULTS Chest radiographs and electrocardiogram: normal Computerized Tomography with contrast of the chest: five pulmonary emboli in the left inferior pulmonary artery and four pulmonary emboli in the right inferior pulmonary artery. No pulmonary infarction, consolidation, atelectasis, or pleural effusion. Transthoracic and transesophageal echocardiograms: normal 2D Doppler, color and spectral Doppler imaging of the neck and extremities: normal D Dimer: 500–1000 Serum coagulopathy work-up otherwise normal FINAL WORKING DIAGNOSIS Bilateral pulmonary emboli secondary to thrombophilia TREATMENT AND OUTCOMES Admitted to pediatric intensive care and anticoagulated with heparin. Anticoagulation with warfarin was initiated and heparin was discontinued. Poor compliance with warfarin and anticoagulation with enoxaparin was initiated. Poor compliance with enoxaparin and patient became symptomatic with dyspnea and retrosternal chest pain. CT scans remained unchanged. Greenfield inferior vena cava filter was placed and anticoagulation with warfarin resumed. Patient developed an essential tremor and major depressive disorder.